Provider Demographics
NPI:1386904506
Name:BACK TO LIFE HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:BACK TO LIFE HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRAILS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-720-3265
Mailing Address - Street 1:5543 EDMONDSON PIKE
Mailing Address - Street 2:195
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-5808
Mailing Address - Country:US
Mailing Address - Phone:615-720-3265
Mailing Address - Fax:615-834-2662
Practice Address - Street 1:1916 PATTERSON ST
Practice Address - Street 2:SUITE 310
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2120
Practice Address - Country:US
Practice Address - Phone:615-720-3265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3973824Medicaid
TN3973824Medicaid
TN3973824Medicare Oscar/Certification
TN3973824Medicare PIN